429 N. Ferncreek Avenue, Orlando, FL 32803
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(407) 777-2071
About
OUR PRACTICE
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Why Choose an FAGD Dentist
SERVICES
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Medical History
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First Name
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Last Name
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Health History
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Have you been hospitalized in the last two years?
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Yes
No
For What?
Have you ever been hospitalized?
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Yes
No
For What?
Are you currently being treated by a physician?
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Yes
No
If Yes:
Have you ever had a serious head or neck injury?
*
Yes
No
If Yes:
Are you taking any medications, pills, or drugs?
*
Yes
No
If Yes:
Do you take, or have you taken, Phen-Fen or Redux?
*
Yes
No
If Yes:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
*
Yes
No
If Yes:
Are you on a special diet?
*
Yes
No
If Yes:
Do you use tobacco?
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Yes
No
Do you use controlled substances?
*
Yes
No
If Yes:
Women: Are you pregnant / Trying to get pregnant?
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Yes
No
Nursing?
*
Yes
No
Taking oral contraceptives?
*
Yes
No
Are you allergic to any of the following?
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Aspirin
*
Yes
No
Penicillin
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Yes
No
Codeine
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Yes
No
Acrylic
*
Yes
No
Metal
*
Yes
No
Latex
*
Yes
No
Sulfa Drugs
*
Yes
No
Local Anesthetics
*
Yes
No
Other?
*
Yes
No
If Yes:
Sleep Medicine Questionnaire
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Have you been diagnosed with sleep apnea?
Yes
No
Do you have a CPAP?
Yes
No
If so, how many nights per week do you wear your CPAP?
On nights when you wear your CPAP, how many hours do you typically wear it?
Do you snore or have you ever been told that you snore, stop breathing, or gasp for air when you sleep?
Yes
No
After a typical night's sleep, do you feel refreshed?
Yes
No
Have you been diagnosed with atrial fibrillation (AFib)?
Yes
No
If you have high blood pressure, is it well-controlled?
Yes
No
If no, how many blood pressure medications are you currently taking?
Do you have, or have you had, any of the following?
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AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores / Fever Blisters
Congenital Heart Disorder
Convulsions
Yellow Jaundice
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells / Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
HayFever
Heart Attack / Failure
Heart Murmur
Heart Pacemaker
Heart Trouble / Disease
Sleep Apnea
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain In Jaw Joints
Parathyroid Disease
Psychiatric Care
Snoring
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach / Intestinal Disease
Stroke
Swelling Of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Have you ever had any serious illnes not listed?
*
Yes
No
If Yes:
Comments
Did you know that we offer cosmetic and therpuetic Botox and Dermal Filler? If you are interested, please check the boxes below.
Fields marked with * are required
Forehead Lines
Lip appearance and texture
Frown lines
Thin Lips
Crow's feet lines
Double chin
Flattened cheeks / sunken cheeks
Thinning or inadequate lashes
Lines and wrinkles around the nose and mouth
Skin appearance and texture
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Date: 4/27/2024
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